Mário Borges Rosa

Erros de medicação: quem foi?

New diagnostic and therapeutic technologies are used with growing frequency, improving the quality of medical assistance and increasing life expectancy. Health care, however, is becoming progressively more expensive and complex. Adverse events related to medical assistance, particularly errors, are becoming public, being debated and judged in courts. Given their training, health workers are not prepared to deal with errors, which are associated with shame, fear and punishment. The approach to errors in the health system is usually individualistic, considering such events as acts of insecurity performed by careless, non-motivated and ill-trained persons. The tendency is to hide errors when they occur, with the result that an important learning opportunity is lost. There is another way to deal with errors, a systemic view that has obtained positive results in sectors such as aviation, anesthesiology and unit-dose drug distribution systems. These systems have varied degrees of safety and should take into account human limitations when designed and applied. A change in paradigm is needed when dealing with drugs, as it is not enough for a drug to have quality assurance, but the complete process of drug use should be safe. Medication errors, avoidable by definition, are at present a serious public health issue, leading to loss of lives and significant financial losses. A systemic approach to medication errors may disclose failures in the process as a whole, and improvements can be implemented to reduce their occurrence.

Erros na prescrição hospitalar de medicamentos potencialmente perigosos

OBJETIVO:Los errores de medicacion son actualmente un problema mundial de salud publica, siendo los mas serios los de prescripcion. El objetivo del estudio fue analizar la practica de la prescripcion de medicamentos de alto riesgo y su relacion con la prevalencia de errores de medicacion en ambiente hospitalario. METODOS: Estudio transversal retrospectivo abarcando 4.026 prescripciones con medicamentos potencialmente peligrosos. Durante 30 dias de 2001, fueron analizadas todas las prescripciones recibidas en la farmacia de un hospital de referencia del estado de Minas Gerais (Sureste de Brasil). Las prescripciones fueron analizadas con relacion a: legibilidad, nombre del paciente, tipo de prescripcion, fecha, caligrafia o grafia, identificacion del prescriptor, analisis del medicamento y uso de abreviaturas. Los errores de prescripcion fueron clasificados como de redaccion o decision, siendo evaluada la influencia del tipo de prescripcion en la ocurrencia de errores. RESULTADOS: Hubo predominio de la prescripcion escrita a mano (45,7%). En 47,0% de las prescripciones escritas a mano, mixtas y pre-digitadas ocurrieron errores en el nombre del paciente, en 33,7% hubo dificultades en la identificacion del prescriptor y 19,3% estaban poco legibles o ilegibles. En un total de 7.148 medicamentos de alto riesgo prescritos, fueron observados 3.177 errores, siendo mas frecuente la omision de informacion (86,5%). Los errores se concentraron principalmente en los medicamentos heparina, fentanil y midazolam; y los sectores de tratamiento intensivo y la neurologia presentaron mayor numero de errores por prescripcion. Se observo el uso intensivo y sin estandarizacion de abreviaturas. Cuando se computaron todos los tipos de errores, se verifico 3,3 por prescripcion. La prescripcion pre-digitada presento menor probabilidad de errores en comparacion con las mixtas o escritas a mano. CONCLUSIONES:Los resultados sugieren la necesidad de la estandarizacion en el proceso de prescripcion y la eliminacion de aquellas hechas a mano. El uso de prescripciones pre-digitadas o editadas podra disminuir los errores relacionados a los medicamentos potencialmente peligrosos.OBJECTIVE Medication errors are currently a worldwide public health issue and it is one of the most serious prescription errors. The objective of the study was to evaluate the practice of prescribing high-alert medications and its association with the prevalence of medication errors in hospital settings. METHODS A retrospective cross-sectional study was conducted including 4,026 prescription order forms of high-alert medications. There were evaluated all prescriptions received at the pharmacy of a reference hospital in the state of Minas Gerais, southeastern Brazil, over a 30-day period in 2001. Prescription were checked for legibility, patient name, type of prescription, date, handwriting or writing, prescriber identification, drug prescribed, and use of abbreviations. Prescription errors were classified as writing or decision errors and how the type of prescription affected the occurrence of errors was assessed. RESULTS Most prescriptions were handwritten (45.7%). In 47.0% of handwritten, mixed and pre-typed prescriptions had patient name errors; the prescriber name was difficult to identify in 33.7%; 19.3% of them were hardly legible or illegible. Of a total of 7,148 high-alert drugs prescribed, 3,177 errors were found, and the most frequent one was missing information (86.5%). Errors occurred mostly in prescriptions of heparin, phentanyl, and midazolam. Intensive care and neurology units had the highest number of errors per prescription. Non-standard abbreviations were frequent and widespread. Overall it was estimated 3.3 errors per prescription order form. Pre-typed prescriptions were less likely to have errors compared to mixed or handwritten prescriptions. CONCLUSIONS The study results show there is a need for standardizing the prescription process and eliminating handwritten prescriptions. The use of pre-typed or edited prescriptions may reduce errors associated to high-alert medications.

Medication errors and drug-dispensing systems in a hospital pharmacy

Pharmacies permeate and interconnect various actions developed in different sectors within the complex process of the use of drugs in a hospital. Dispensing failures mean that a breach has occurred in one of the last safety links in the use of drugs. Although most failures do not harm patients, their existence suggests fragility in the process and indicates an increased risk of severe accidents. Present concepts on drug-related incidents may be classified as side effects, adverse effects, and medication errors. Among these are dispensing errors, usually associated with poor safety and inefficient dispensing systems. Factors associated with dispensing errors may be communication failures, problems related to package labels, work overload, the physical structure of the working environment, distraction and interruption, the use of incorrect and outdated information sources and the lack of patient knowledge and education about the drugs they use. So called banal dispensing errors reach significant epidemiological levels. The purpose of this paper, which is part of a study on the occurrence of dispensing errors in the pharmacy of a large hospital, is to review the main concepts that guide studies on adverse effects and to provide an update on dispensing errors.

Drug-dispensing errors in the hospital pharmacy

OBJECTIVE To determine the dispensing error rate and to identify factors associated with them, and to propose prevention actions. METHODS A cross-sectional study focusing on the occurrence of dispensing errors in a general hospital in Belo Horizonte that uses a mixed system (a combination of multidose and unit dose systems) of collective and individualized dosing. RESULTS A total of 422 prescription order forms were analyzed, registering 81.8% with at least 1 dispensing error. Opportunities for errors were higher in the pretyped prescription order forms (odds ratio = 4.5; P <.001), in those with 9 or more drugs (odds ratio = 4.0; P <.001), and with those for injectable drugs (odds ratio = 5.0; P <.001). One of the teams of professionals had a higher chance of errors (odds ratio = 2.0; P =.02). A multivariate analysis ratified these results. CONCLUSIONS The dispensing system at the pharmacy can produce many latent failures and does not have an adequate control; it has several conditions that predispose it to the occurrence of errors, contributing to the high rate reported.OBJETIVO: Determinar a taxa de erros de dispensacao e identificar fatores associados, propondo acoes de prevencao. METODOS: Estudo transversal investigou-se a ocorrencia de erros de dispensacao em um hospital geral de Belo Horizonte que emprega um sistema misto de dose coletiva e individualizada. RESULTADOS: Foram analisadas 422 prescricoes, registrando em 81,8% destas pelo menos um erro de dispensacao. Oportunidades de erros foram maiores nas prescricoes pre-digitadas (Odds Ratio=4,5; p<0,001), naquelas com nove ou mais medicamentos (Odds Ratio=4,0; p<0,001) e com os injetaveis (Odds Ratio=5,0; p<0,001). Uma das equipes de profissionais apresentou maior chance de erros (Odds Ratio=2,0; p=0,02). A analise multivariada ratifica estes resultados. CONCLUSAO: Conclui-se que o sistema de dispensacao da farmacia apresenta muitas falhas latentes e poucas defesas, com diversas condicoes que predispoe a ocorrencia de erros, contribuindo para a elevada taxa registrada.

Concomitant prescribing and dispensing errors at a Brazilian hospital: a descriptive study

OBJECTIVE: To analyze the prevalence and types of prescribing and dispensing errors occurring with high-alert medications and to propose preventive measures to avoid errors with these medications. INTRODUCTION: The prevalence of adverse events in health care has increased, and medication errors are probably the most common cause of these events. Pediatric patients are known to be a high-risk group and are an important target in medication error prevention. METHODS: Observers collected data on prescribing and dispensing errors occurring with high-alert medications for pediatric inpatients in a university hospital. In addition to classifying the types of error that occurred, we identified cases of concomitant prescribing and dispensing errors. RESULTS: One or more prescribing errors, totaling 1,632 errors, were found in 632 (89.6%) of the 705 high-alert medications that were prescribed and dispensed. We also identified at least one dispensing error in each high-alert medication dispensed, totaling 1,707 errors. Among these dispensing errors, 723 (42.4%) content errors occurred concomitantly with the prescribing errors. A subset of dispensing errors may have occurred because of poor prescription quality. The observed concomitancy should be examined carefully because improvements in the prescribing process could potentially prevent these problems. CONCLUSION: The system of drug prescribing and dispensing at the hospital investigated in this study should be improved by incorporating the best practices of medication safety and preventing medication errors. High-alert medications may be used as triggers for improving the safety of the drug-utilization system.

Errors in hospital prescriptions of high-alert medications

OBJETIVO:Los errores de medicacion son actualmente un problema mundial de salud publica, siendo los mas serios los de prescripcion. El objetivo del estudio fue analizar la practica de la prescripcion de medicamentos de alto riesgo y su relacion con la prevalencia de errores de medicacion en ambiente hospitalario. METODOS: Estudio transversal retrospectivo abarcando 4.026 prescripciones con medicamentos potencialmente peligrosos. Durante 30 dias de 2001, fueron analizadas todas las prescripciones recibidas en la farmacia de un hospital de referencia del estado de Minas Gerais (Sureste de Brasil). Las prescripciones fueron analizadas con relacion a: legibilidad, nombre del paciente, tipo de prescripcion, fecha, caligrafia o grafia, identificacion del prescriptor, analisis del medicamento y uso de abreviaturas. Los errores de prescripcion fueron clasificados como de redaccion o decision, siendo evaluada la influencia del tipo de prescripcion en la ocurrencia de errores. RESULTADOS: Hubo predominio de la prescripcion escrita a mano (45,7%). En 47,0% de las prescripciones escritas a mano, mixtas y pre-digitadas ocurrieron errores en el nombre del paciente, en 33,7% hubo dificultades en la identificacion del prescriptor y 19,3% estaban poco legibles o ilegibles. En un total de 7.148 medicamentos de alto riesgo prescritos, fueron observados 3.177 errores, siendo mas frecuente la omision de informacion (86,5%). Los errores se concentraron principalmente en los medicamentos heparina, fentanil y midazolam; y los sectores de tratamiento intensivo y la neurologia presentaron mayor numero de errores por prescripcion. Se observo el uso intensivo y sin estandarizacion de abreviaturas. Cuando se computaron todos los tipos de errores, se verifico 3,3 por prescripcion. La prescripcion pre-digitada presento menor probabilidad de errores en comparacion con las mixtas o escritas a mano. CONCLUSIONES:Los resultados sugieren la necesidad de la estandarizacion en el proceso de prescripcion y la eliminacion de aquellas hechas a mano. El uso de prescripciones pre-digitadas o editadas podra disminuir los errores relacionados a los medicamentos potencialmente peligrosos.OBJECTIVE Medication errors are currently a worldwide public health issue and it is one of the most serious prescription errors. The objective of the study was to evaluate the practice of prescribing high-alert medications and its association with the prevalence of medication errors in hospital settings. METHODS A retrospective cross-sectional study was conducted including 4,026 prescription order forms of high-alert medications. There were evaluated all prescriptions received at the pharmacy of a reference hospital in the state of Minas Gerais, southeastern Brazil, over a 30-day period in 2001. Prescription were checked for legibility, patient name, type of prescription, date, handwriting or writing, prescriber identification, drug prescribed, and use of abbreviations. Prescription errors were classified as writing or decision errors and how the type of prescription affected the occurrence of errors was assessed. RESULTS Most prescriptions were handwritten (45.7%). In 47.0% of handwritten, mixed and pre-typed prescriptions had patient name errors; the prescriber name was difficult to identify in 33.7%; 19.3% of them were hardly legible or illegible. Of a total of 7,148 high-alert drugs prescribed, 3,177 errors were found, and the most frequent one was missing information (86.5%). Errors occurred mostly in prescriptions of heparin, phentanyl, and midazolam. Intensive care and neurology units had the highest number of errors per prescription. Non-standard abbreviations were frequent and widespread. Overall it was estimated 3.3 errors per prescription order form. Pre-typed prescriptions were less likely to have errors compared to mixed or handwritten prescriptions. CONCLUSIONS The study results show there is a need for standardizing the prescription process and eliminating handwritten prescriptions. The use of pre-typed or edited prescriptions may reduce errors associated to high-alert medications.

Drug shortage: a public health problem

that has increased in Brazil in the last decade, interfer-ing in all levels of care, both public and private, from primary to specialized care. As a complex and multifactorial phenomenon, it is influ-enced by elements of pharmaceutical logistics and diverse political factors, from broad defini-tions for the health and science and technology sectors to quality of action in the customs, fis-cal, and health regulatory agencies

Descontinuação de medicamentos: um problema de saúde pública

that has increased in Brazil in the last decade, interfer-ing in all levels of care, both public and private, from primary to specialized care. As a complex and multifactorial phenomenon, it is influ-enced by elements of pharmaceutical logistics and diverse political factors, from broad defini-tions for the health and science and technology sectors to quality of action in the customs, fis-cal, and health regulatory agencies

Discontinuación de los medicamentos: un problema de salud pública

that has increased in Brazil in the last decade, interfer-ing in all levels of care, both public and private, from primary to specialized care. As a complex and multifactorial phenomenon, it is influ-enced by elements of pharmaceutical logistics and diverse political factors, from broad defini-tions for the health and science and technology sectors to quality of action in the customs, fis-cal, and health regulatory agencies

Errores en la prescripción hospitalaria de medicamentos potencialmente peligrosos

OBJETIVO:Los errores de medicacion son actualmente un problema mundial de salud publica, siendo los mas serios los de prescripcion. El objetivo del estudio fue analizar la practica de la prescripcion de medicamentos de alto riesgo y su relacion con la prevalencia de errores de medicacion en ambiente hospitalario. METODOS: Estudio transversal retrospectivo abarcando 4.026 prescripciones con medicamentos potencialmente peligrosos. Durante 30 dias de 2001, fueron analizadas todas las prescripciones recibidas en la farmacia de un hospital de referencia del estado de Minas Gerais (Sureste de Brasil). Las prescripciones fueron analizadas con relacion a: legibilidad, nombre del paciente, tipo de prescripcion, fecha, caligrafia o grafia, identificacion del prescriptor, analisis del medicamento y uso de abreviaturas. Los errores de prescripcion fueron clasificados como de redaccion o decision, siendo evaluada la influencia del tipo de prescripcion en la ocurrencia de errores. RESULTADOS: Hubo predominio de la prescripcion escrita a mano (45,7%). En 47,0% de las prescripciones escritas a mano, mixtas y pre-digitadas ocurrieron errores en el nombre del paciente, en 33,7% hubo dificultades en la identificacion del prescriptor y 19,3% estaban poco legibles o ilegibles. En un total de 7.148 medicamentos de alto riesgo prescritos, fueron observados 3.177 errores, siendo mas frecuente la omision de informacion (86,5%). Los errores se concentraron principalmente en los medicamentos heparina, fentanil y midazolam; y los sectores de tratamiento intensivo y la neurologia presentaron mayor numero de errores por prescripcion. Se observo el uso intensivo y sin estandarizacion de abreviaturas. Cuando se computaron todos los tipos de errores, se verifico 3,3 por prescripcion. La prescripcion pre-digitada presento menor probabilidad de errores en comparacion con las mixtas o escritas a mano. CONCLUSIONES:Los resultados sugieren la necesidad de la estandarizacion en el proceso de prescripcion y la eliminacion de aquellas hechas a mano. El uso de prescripciones pre-digitadas o editadas podra disminuir los errores relacionados a los medicamentos potencialmente peligrosos.OBJECTIVE Medication errors are currently a worldwide public health issue and it is one of the most serious prescription errors. The objective of the study was to evaluate the practice of prescribing high-alert medications and its association with the prevalence of medication errors in hospital settings. METHODS A retrospective cross-sectional study was conducted including 4,026 prescription order forms of high-alert medications. There were evaluated all prescriptions received at the pharmacy of a reference hospital in the state of Minas Gerais, southeastern Brazil, over a 30-day period in 2001. Prescription were checked for legibility, patient name, type of prescription, date, handwriting or writing, prescriber identification, drug prescribed, and use of abbreviations. Prescription errors were classified as writing or decision errors and how the type of prescription affected the occurrence of errors was assessed. RESULTS Most prescriptions were handwritten (45.7%). In 47.0% of handwritten, mixed and pre-typed prescriptions had patient name errors; the prescriber name was difficult to identify in 33.7%; 19.3% of them were hardly legible or illegible. Of a total of 7,148 high-alert drugs prescribed, 3,177 errors were found, and the most frequent one was missing information (86.5%). Errors occurred mostly in prescriptions of heparin, phentanyl, and midazolam. Intensive care and neurology units had the highest number of errors per prescription. Non-standard abbreviations were frequent and widespread. Overall it was estimated 3.3 errors per prescription order form. Pre-typed prescriptions were less likely to have errors compared to mixed or handwritten prescriptions. CONCLUSIONS The study results show there is a need for standardizing the prescription process and eliminating handwritten prescriptions. The use of pre-typed or edited prescriptions may reduce errors associated to high-alert medications.